Sequoia New Patient Request Form

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Sequoia New Patient Request Form

The Sequoia tree is known for i's resiliency and ability to withstand the challenging elements in life, just like we experience in recovery. Our program is rooted in a foundation of ethical, evidenced based, and holistic care. We are here to support you in finding your own empowerment on your healing journey in recovery

Your Name(Required)

First Name Last Name

Your Phone(Required)

Date of Birth(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Current address

Street Address Address Line 2 City ZIP Code

Biological Gender(Required)

Gender Identity

Preferred Pronoun(Required)

Insurance Carrier?(Required)

Type of Insurance Coverage?

Insurance Policy Number?(Required)

How can we support you?(Required)

Preferred method of contact for consultation(Required)

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